NR 565 Final Exam Advanced Pharmacology Study guide - Chamberlain

• Labs used to diagnose Hyo/hyper thyroidism TSH, T3, T4, free T3 and T4 • Timeframe for re-check of labs after starting levothyroxine Retest serum TSH in 6-8 weeks and after any dosage change • Hypothyroidism (Hashimotos) - S/S - Abnormally high levels of TSH is HYPO hypothyroidism - Pale, puffy, expressionless - Skin is cold and dry - Hair is brittle, and hair loss occurs - Heart rate and temp are low - Lethargy, fatigue, intolerance to cold • Hyperthyroidism (Graves disease) - Heartbeat is rapid and strong & dysrhythmias and angina may occur - CNS is stimulated, resulting in nervousness, insomnia, rapid thought flow, rapid speech - Skeletal muscles may weaken and atrophy - Metabolic rate is raided, resulting in increased heat and body temp - Appetite is increased, weight loss occurs exophthalmos • Normal TSH levels 0.6-6 • T3 levels 80-220 • T4 levels 4.5-12.5 • radioactive iodine destroys the thyroid gland -used for hyperthyroidism • Treatment of Thyroid storm - PTU - High doses of iodine solution - Methimazole is given to suppress thyroid function synthesis and first line for hyperthyroidism - Beta blockers is given to reduce heart rate - Sedation, cooling and giving glucocorticoids and IV fluids • Methamazole (Tapazole) - First line drug for hyperthyroidism - Avoided in first trimester of pregnancy • Results of not treating hypothyroidism during pregnancy - Permanent neuropsychological deficits • Medication to treat symptoms of hyperthyroidism (notice this is treating symptoms and not the hyperthyroidism itself) - Beta blockers suppress tachycardia - Non radioactive iodine - Exophthalmos can be treated with oral glucocorticoids • Drug/Food/Supplement interactions with levothyroxine - Calcium, iron, antacids, magnesium - Should be taken on an empty stomach -- can take levo an hour later - Phenytoin, carbamazepine, rifampin, Sertraline, and phenobarbital accelerate levothyroxine - Warfarin can be enhanced - Thyroid hormones increases cardiac responsiveness to catecholamines, thereby increasing the risk for catecholamine induced dysrhythmias • How to confirm a diagnosis prior to beginning treatment - Fasting plasma glucose 126mg/dL - Random plasma glucose 200mg/dL - Oral glucose tolerance test 2-h plasma glucose 200 - Hemoglobin A1C 6.5& or higher • Beta blockers and diabetes BB mask hypoglycemia • Biguanides CI Renal insufficiency and heart failure?? double check • A1C - Should be rechecked after 2 to 3 months - less than 6.5 • A1C greater than 10 combination therapy greater than 9 = consider dual therapy • Pioglitazone contraindications - Associated with HF, so if HF is diagnosed Pioglitazone should be discontinued - Increase the risk of fractures in women • Which drug class should be considered for diabetes prior to insulin? - Biguanides (Metformin) • Ratio of basal insulin to rapid-acting insulin in total daily dose (TDD) of insulin - kg of patient X 0.6 = TDD • Know the carbohydrate-to insulin ratio when calculating basal insulin - 500/ TDD = carb ratio • GLP-1 MOA -Glucagon-like peptide 1 - Augment effects of incretin hormone GLP-1 - Lower blood sugar by slowing gastric emptying, stimulating glucose dependent insulin release, suppressing postprandial glucagon release, and reducing appetite. • GLP-1 examples Exenatide, liraglutide • TZDs - Decrease insulin resistance - Decrease insulin resistance and thereby increase glucose uptake by muscle and adipose tissue and decrease glucose production by the liver • TZD examples - Pioglitazone (Actos) - Rosiglitazone (Avandia) • DPP-4 inhibitors - Enhance actions of incretin hormones - Enhance the activity of incretins and thereby increase insulin release, reduce glucagon release, and decrease hepatic glucose production • DPP-4 inhibitors examples Linagliptin, saxagliptin, sitagliptin • Sulfonylureas MOA - Stimulate insulin to release from pancreatic islet - Promote insulin secretion by the pancreas; may also increase tissue response to insulin - Do not let pregnant women take • Sulfonylureas examples glipizide, glyburide, glimepiride • SLGT2 inhibitors - Limits reabsorption of glucose in the renal tubules - Increase glucose secretion via the urine by inhibiting SGLT-2 in the kidney tubules decreasing glucose levels and inducing weight loss by caloric loss through urine. - Don't give with someone who has UTI's • SLGT2 inhibitors examples Canagliflozin Dapagliflozin Empagliflozin • Which diabetic medication(s) come with a concern of hypoglycemia? - Sulfonylureas - Glinides - Dipeptidyl Peptidase - 4 Inhibitors - Glucagon - like peptide Receptor Agonists • Who is at risk for toxicity and why for Methylxanthines? - People who are smokers require higher doses, so if you stop smoking levels will rise to toxic levels • Step 1 therapy - SABA(beta 2 antagonists) as needed • Intermittent Asthma Symptoms less than 2 times/week 2 nighttime symptoms/month Tx with SABA • mild persistent asthma Symptoms occur more than 2x/wk, but not daily 3-4 times/ month at night • moderate persistent asthma Daily More than once/week but less than nightly • severe asthma several times daily often nightly • SABA examples albuterol, levalbuterol • Benefits of SABAs - Used for asthma exacerbations • Patient instructions for SABAs • Why is it important to know the frequency a patient is using their SABA? - could mean life or death • LABA examples Salmeterol Tiotropium Arfomoterol • Benefits of LABAs and its use in COPD - long term control Dosins is done on a fixed schedule, not PRN. LABAs are preferred over SABAs for patients with stable COPD • Inhaled Corticoid Steroid examples -Beclomethasone dipropionate - Qvar - Budesonide - Pulmicort - Flunisolide - Aerospan - Ciclesonide - Alvesco - Fluticasone propionate – Flovent • Benefits of ICS - Very effective for reducing inflammation - First line therapy for management of the inflammatory component of asthma • At what point would an oral steroid be prescribed? - Moderate to severe persistent asthma - Hospitalized recently or triggers • When would roflumilast be indicated for a COPD patient? - Reduces inflammation - Only approved for asthma - Not intended during pregnancy • Nicotine Replacement and how does is work? - Caffeine can intensify the adverse effects of theophylline on the heart and CNS and can decrease theophylline metabolism.